CO2 surgical laser for treatment of stress urinary incontinence in women: a randomized controlled trial

BACKGROUND

Stress urinary incontinence is a common condition that can be treated conservatively and/or surgically. Given the risks of surgery, developing effective nonsurgical treatment options would be beneficial. Some studies have suggested that laser therapy may improve or cure stress urinary incontinence. However, there is a lack of sham-controlled randomized controlled trials to judge treatment efficacy.

OBJECTIVE

This study aimed to compare the effects of CO₂ vaginal laser vs sham therapy for treating stress urinary incontinence.

STUDY DESIGN

This was a multicenter, participant-blinded, sham-controlled, parallel group (1:1) superiority randomized controlled trial performed in outpatient clinics in 2 hospitals. We included women aged 18 to 80 years with objective and subjective stress urinary incontinence. Participants had undertaken or declined supervised pelvic floor muscle training. Intervention was performed using a CO₂ fractionated vaginal laser. Participants underwent 3 treatments, 4 weeks apart, with increasing energy and density settings. Sham treatment was performed using an identical technique with a deactivated pedal. The primary outcome was the subjective stress urinary incontinence rate (proportion with leak with cough, sneeze, or laughter) at 3 months after completion of treatment. Secondary outcomes included objective stress urinary incontinence, change in the disease-specific patient-reported outcomes, health-related quality of life, and adverse effects. Categorical outcomes were compared using the chi square test and continuous outcomes using analysis of covariance, adjusting for the baseline score.

RESULTS

There were 52 participants who received laser and 49 who received sham treatment. One participant in each group withdrew from the study before the endpoint, and 2 participants in the laser group did not participate in the follow-up visits. Participant mean age was 53 (34-79) years. Mean body mass index was 26.1 (18.1-49.6); 90% were vaginally parous. At 3 months, there was no difference between the sham and active treatment arm in subjective stress urinary incontinence (46 [96%] vs 48 [98%]; relative risk, 0.98 [95% confidence interval, 0.91-1.05]; P=.55) or in objective stress urinary incontinence (37 [80%] vs 33 [80%]; relative risk, 0.99 [95% confidence interval, 0.81-1.23]; P=.995). Patient-reported outcomes and health-related quality of life were also comparable between the groups. Vaginal bleeding occurred in 3 participants after laser and 1 participant after sham treatment. Pain during treatment did not differ between laser and sham treatment.

CONCLUSION

We were unable to show an improvement in stress urinary incontinence after CO₂ vaginal laser therapy compared with sham treatment.

Imaging-Based Surrogate Markers of Epidermal Growth Factor Receptor Mutation in Lung Adenocarcinoma: A Local Perspective

PURPOSE

To identify computed tomography (CT) features of epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma in Canadian population and whether imaging-based surrogate markers of EGFR mutation in our population were similar to those found in the Asian population.

MATERIALS AND METHODS

Pretreatment CT scans of 223 patients with adenocarcinoma of the lung (112 with EGFR mutation and 111 without mutation) were retrospectively assessed for 20 specific CT features by 2 radiologists, who were blinded to the status of EGFR mutation. Univariate and multivariate logistic regression analyses as well as areas under the receiver operating characteristic curve were performed to discriminate characteristics of EGFR-activating mutation features.

RESULTS

Epidermal growth factor receptor mutation-positive adenocarcinomas were more frequently found in female (P < .03), less than 20 pack-year smoking history (P < .001), smaller tumor (P < .01), spiculated margins (P < .05), without centrilobular emphysema (P < .001), and without lymphadenopathy (P < .05), similarly to the Asian population. Multivariate logistic regression analyses of combined clinical and radiological features identified less than 20 pack-year smoking history, smaller tumor diameter, fine or coarse spiculations, noncentral location of the tumor, and lack of centrilobular emphysema and pleural attachment as the strongest independent prognostic factors for the presence of an EGFR mutation. These combined features improved prognostic ability area under the curve to 0.879, compared to 0.788 for clinical features only.

CONCLUSION

Several CT findings may help predict the presence of an activating mutation in EGFR in lung adenocarcinomas in our Canadian population. Combining clinical and radiological features improves prognostic ability to determine the EGFR mutation status compared to clinical features alone.

Patient attitude and acceptance towards episiotomy during pregnancy before and after information provision: a questionnaire

INTRODUCTION AND HYPOTHESIS

Evidence regarding how women feel about episiotomies is not recorded in the literature. As the most common surgical procedure, there is a need to understand how women feel about episiotomy.

METHODS

The primary outcome was to identify the percentage of women who would accept an episiotomy if required. A literature review was compiled to provide nulliparous women in their third trimester with evidence-based information about episiotomies and perineal tears. Questions eliciting demographics, pre-information level of anxiety and acceptance of episiotomy were asked. After reading the information sheets, anxiety and knowledge were assessed again. Changes in anxiety levels from pre- to post-information were investigated using paired samples t tests. Because anxiety was measured on a scale, we assessed potential departures from normality by using the Wilcoxon signed-rank test. Questions also assessed the value women placed on this form of education.

RESULTS

There were 105 responses, with 88% accepting episiotomy, 2% declining and 10% seeking more information to decide. Eighty-one percent of women agreed that the information provided helped them to understand more about childbirth and 62% agreed that they felt more comfortable with the birthing process after reading the material. There was a reduction in anxiety levels regarding episiotomies after reading information (p = 0.002) and perineal tears (p = 0.02).

CONCLUSIONS

Most women will accept an episiotomy if required. Antenatal education about episiotomies is important to women and helps them feel more comfortable with the birthing process. Written information increases acceptance and reduces anxiety levels regarding episiotomies.

Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy

Morbid obesity is a barrier to renal transplantation and is inadequately addressed by medical therapy. We present results of a prospective evaluation of laparoscopic sleeve gastrectomy (LSG) for patients failing to achieve significant weight loss with medical therapy. Over a 25-month period, 52 obese renal transplant candidates meeting NIH guidelines for metabolic surgery underwent LSG. Mean age was 50.0 ± 10.0 years with an average preoperative BMI of 43.0 ± 5.4 kg/m(2) (range 35.8-67.7 kg/m(2)). Follow-up after LSG was 220 ± 152 days (range 26-733 days) with last BMI of 36.3 ± 5.3 kg/m(2) (range 29.2-49.8 kg/m(2)) with 29 (55.8%) patients achieving goal BMI of <35 kg/m(2) at 92 ± 92 days (range 13-420 days). The mean percentage of excess weight loss (%EWL) was 32.1 ± 17.6% (range 6.7-93.8%). A segmented regression model was used to compare medical therapy versus LSG. This revealed a statistically significant increase in the BMI reduction rate (0.3 kg/m(2)/month versus 1.1 kg/m(2)/month, p < 0.0001). Patients also experienced a 40.9% decrease in anti-hypertensive medications (p < 0.001) and a 49.7% decrease in total daily insulin dose (p < 0.001). LSG is a safe and effective means for addressing obesity in kidney transplant candidates in the context of a multidisciplinary approach.

Taiwanese nurses' cognition and attitudes towards the Magnet Hospitals Recognition Programme

AIMS

To explore the relevance and feasibility of using the Magnet Recognition Programme (MRP) at a Taiwanese hospital.

BACKGROUND

Since no hospitals in Taiwan have applied for American Nurses Credentialing Center Magnet Recognition, and the American medical system and customs are different from those in Taiwan, this study explores whether or not the MRP is appropriate for Taiwanese hospitals.

METHOD

This study used a cross-sectional design with data collected from 905 nurses at a 1200-bed Taiwanese military hospital. The authors created the structured questionnaire from a framework based on the 14 Forces of Magnetism. The study used descriptive and inferential statistical analyses to explain the nurses' cognitions and attitudes towards the MRP and to discover if variations in these concepts occurred across nurses' demographics and their job classification.

FINDINGS

The mean nurses' cognitive score on each item varies from 3.3 to 4.1, and the mean nurses' attitude score on each item varies from 3.0 to 4.0 (both with the highest possible score related to the 14 Forces of Magnetism being 5.0). Using regression analysis, overall cognitive score, working in the operating room, or the sub-critical Neonatal Care Unit, and part-time hours of work explained 42% of the variance in the total attitude score towards the MRP.

CONCLUSION

The findings indicate that when nurses have a higher cognition towards MRP, the more positive are their attitudes towards seeking the MRP. Using these findings and information about the nurses, the authors suggest strategies that hospital executives and nursing supervisors can use to improve nurses' cognition and attitudes when preparing to seek recognition through the MRP.

Regulatory effect of histamine on the barrier function of intestinal mucosal

OBJECTIVES

To investigate the regulatory effect of histamine on the barrier function of intestinal mucosal.

METHODS

The monolayer Caco-2 cell system in vitro and the model of hemorrhage infection in rats in vivo were established as experimental models. The amount of bacterial translocation was taken as an index of the effect of histamine and its receptor antagon, cimetidine on the intestinal mucosal barrier function.

RESULTS

(1) The in vitro experiment showed that after treatment with histamine, the CFU of Escherichia coli 075 invading into Caco-2 cells were much lower than that in the control group (P < 0.05). (2) The animal experiment showed that in the histamine group (hemorrhage infection rats treated with histamine), the average numbers of bacteria in the liver and lymph nodes were much lower than that in control group (P < 0.05). The mean bacterial number in the cimetidine group (hemorrhage infection rats treated both with histamine and cimetidine) was more than that in the histamine group, but without statistical signification (P > 0.05). But the rate of translocation to the liver between histamine group (37.5%) and cimetidine group (100%) was statistically different (P < 0.05)

CONCLUSION

Small concentration of histamine can inhibit bacteria from entering epithelial cells and inhibit intestinal bacterial translocation.

Histocompatibility testing predicts acute rejection risk in early corticosteroid withdrawal regimens

Histocompatibility testing has been shown to predict acute rejection risk in steroid-based immunosuppression. However, little evidence exists of its ability to predict acute rejection risk in corticosteroid-free patients, with no evidence in early corticosteroid withdrawal (CSWD) under modern immunosuppression. The purpose of this study was to evaluate the ability of histocompatibility testing to identify patients at high risk for acute rejection after early CSWD.

METHODS

One hundred eighty-one patients were entered into six IRB-approved early CSWD regimens. Histocompatibility testing included serologic PRA, flow cytometric PRA testing by Class I and Class II MHC beads, and B cell crossmatching with pronase treatment. All rejection episodes were biopsy proven, and grading was assigned using Banff criteria. Influence of individual tests was examined using Chi square univariate and multivariate logistic regression analysis.

RESULTS

Median follow-up was 23.5 months (range 7-48 months). Of 181 patients, 16% were repeat transplant recipients, 36% received deceased donor renal transplants, 48% received living related donor renal transplants, and 16% received living unrelated transplants. Overall patient survival was 97%, and death-censored graft survival was 96.5%. Acute rejection rates in the entire follow-up period were 17.7%. 12.4% in primary transplant recipients and 37% in repeat transplant recipients. Multivariate analysis revealed that HLA AB and DR locus mismatching were associated with increased acute rejection risk. Similarly, serologic PRA analysis predicted acute rejection risk; however, flow cytometry crossmatching did not predict acute rejection risk. The greatest single influence on acute rejection risk appeared to be a flow cytometric B cell crossmatch (7.94-fold increased risk). In conclusion, histocompatibility testing can identify patients at high risk for acute rejection following early CSWD. HLA matching, serologic PRA testing, and flow cytometry-based B cell crossmatching can all be used to predict acute rejection risk.

A prospective, pilot study of early corticosteroid cessation in high-immunologic-risk patients: the Cincinnati experience

BACKGROUND

The first prospective trial of steroid withdrawal dedicated to high-immunologic-risk patients is reported herein.

METHODS

Twenty-five patients were enrolled prospectively in an IRB-approved HIPAA-compliant protocol. Immunosuppression included corticosteroid withdrawal (CSWD) at 7 days, tacrolimus (target trough level 4 to 8 ng/mL), sirolimus (target trough level 8 to 12 ng/mL), and Mycophenolate Mofetil (2 g/d). Induction with daclizumab (2 mg/kg) on posttransplant days (PTD) 0 and 14 was administered to the first 10 patients. The protocol for the next 15 patients was modified because of high acute rejection rates to include received T-cell-depleting antibody induction therapy with thymoglobulin (1.5 mg/kg) on PTDs 0 and 2 followed by daclizumab on Postoperative day (POD) 14. Recipient inclusion criteria included: (1) repeat transplant recipients; or (2) patients with a peak PRA > or =25%. All rejection episodes were diagnosed by biopsy and graded using Banff '97 criteria.

RESULTS

Twenty-five patients were enrolled and median follow-up was 402 days. Forty percent of recipients were black, 68% of patients were repeat transplant recipients, 68% received deceased donor kidneys, and 36% had a peak flow PRA >25%. Overall acute rejection, graft survival, and patient survival rates of 40%, 88%, and 96%, respectively, were observed for the duration of the study. Acute rejection occurred in 6 of 10 patients (60%) with daclizumab induction; however, acute rejection rates fell to 27% when thymoglobulin was introduced (P = .1).

CONCLUSIONS

This study supports our previous observations in a multivariate analysis of early CSWD patients, wherein polyclonal antibody induction therapy reduced acute rejection. High-immunologic-risk patients may be able to undergo early CSWD with acceptable rates of acute rejection.

Corticosteroid avoidance ameliorates lymphocele formation and wound healing complications associated with sirolimus therapy

INTRODUCTION

Sirolimus (RAPA) and corticosteroids (CS) both inhibit wound healing. To evaluate the possibility that RAPA and CS have additive effects on wound healing, we evaluated the effects of corticosteroid avoidance (CSAV) on wound healing complications in patients treated with RAPA.

METHODS

One hundred nine patients treated with a CSAV regimen (no pretransplantation or posttransplantation CS) were compared with a historical control group (n = 72) that received cyclosporine (CsA), mycophenolate mofetil (MMF), and CS. The CSAV group received low-dose CsA, MMF, RAPA, and thymoglobulin induction. Complications were classified as follows: wound healing complications (WHC) or infectious wound complications (IWC). WHC included lymphocele, hernia, dehiscence, diastasis, and skin edge separation. IWC included wound abscess and empiric antibiotic therapy for wound erythema.

RESULTS

The CSAV group was largely CS-free: 11% of patients received CS for rejection, 12% of patients received CS for recurrent disease, and 85% of patients are currently off CS. The CSAV group had a significantly lower incidence of WHC (13.7% vs 28%; P = .03) and lymphoceles (5.5% vs 16%; P = .02) than the control group. There was no difference in the incidence of IWC between the 2 groups. Patients who received CSAV were 18% less likely (P = .57) to develop any type of complication, 41% less likely (P = .20) to develop a WHC, and 71% less likely (P = .018) to develop a lymphocele.

CONCLUSIONS

CSAV in a RAPA-based regimen results in a marked reduction in WHC and lymphoceles. Therefore, CSAV provides a promising approach for addressing WHC associated with RAPA therapy.

Global Cardiovascular Risk Under Early Corticosteroid Cessation Decreases Progressively in the First Year Following Renal Transplantation

A primary reason to eliminate corticosteroids from immunosuppressive regimens in solid organ transplant recipients is improved cardiovascular risk profiles. Although a number of studies have documented that corticosteroid withdrawal (CSWD) regimens reduce hypertension, hyperlipidemia, diabetes, and weight gain, global assessments of cardiovascular risk under CSWD have not been reported. The purpose of this study was to document cardiovascular risk under CSWD using a global risk assessment by Framingham risk assessment.

METHODS

Framingham global cardiovascular risk assessments were performed at baseline and 3, 6, and 12 months posttransplant on patients enrolled in prospective, IRB-approved early (<7 days of corticosteroids) CSWD trials. Framingham score was based on age, sex, presence of diabetes, HDL and total cholesterol, and systolic blood pressure. All patients were nonsmokers. Left ventricular hypertrophy assessment by EKG criteria was not available at all time points and therefore were not included.

RESULTS

One hundred eighty-three patients were included in the analysis. Fourteen percent of patients had evidence of coronary heart disease (prior MI, CABG, PTCA, or significant cardiovascular disease as evidenced by angiography) prior to transplant. Complete information was available for 160 patients at baseline, 132 at 1, 3, and 6 months, and 93 at 12 months posttransplant. Mean 10-year risk (expressed as percent) for developing coronary heart disease decreased over time: 8.03 at baseline, 8.31 at 3 months, 7.40 at 6 months, and 7.20 at 12 months, indicating that global cardiovascular risk fell at 1 year posttransplant by about 10% in renal transplant recipients undergoing early CSWD.

CONCLUSIONS

Estimation of cardiovascular risk by Framingham risk factor assessment allows incorporation of several cardiovascular risk factors into a single estimate, thereby accounting for differential effects of each individual factor on global cardiovascular risk. This experience indicates that global cardiovascular risk decreases by approximately 10% at 1 year posttransplant in renal transplant recipients who undergo early corticosteroid withdrawal (CSWD).

African American Renal Transplant Recipients Benefit From Early Corticosteroid Withdrawal Under Modern Immunosuppression

African Americans have historically been considered high-risk renal transplant recipients due to increased rejection rates and reduced long-term graft survival. Modern immunosuppression has reduced rejections and improved graft survival in African Americans and may allow successful corticosteroid withdrawal. Outcomes in 56 African Americans were compared to 56 non-African Americans enrolled in early withdrawal protocols. Results are reported as African American versus non-African American. Acute rejection at 1 year was 23% and 18% (P = NS), while patient and graft survival was 96% versus 98% and 91% versus 91% (P = NS), respectively. In conclusion, early withdrawal in African Americans is associated with acceptable rejection rates and excellent patient and graft survival, indicating that the risks and benefits of early withdrawal are similar between African Americans and non-African Americans. Additional followup is needed to determine long-term renal function, graft survival, and cardiovascular risk in African Americans with early steroid withdrawal.

Basic and clinical research in polyomavirus nephropathy

Over the last decade, polyomavirus nephropathy (PVN) has emerged as an important cause of renal allograft dysfunction and graft loss. PVN occurs with a prevalence of 1%-8% in renal transplant recipients and is most commonly reported within the first 12 months posttransplant. The human polyomavirus, BK virus, is thought to be the primary etiologic agent of PVN. Risk factors for PVN are not well defined and are most likely a result of a complex interaction between multiple donor and recipient factors. Definitive diagnosis of PVN is made through histological assessment of a renal allograft biopsy. Recent studies have also evaluated noninvasive urine and serum markers for screening of BK virus replication and as adjunct tools in PVN diagnosis and monitoring. The principal treatment for PVN is immunosuppression reduction, but this must be balanced against the risks of rejection. If rejection occurs concurrently with PVN, a brief increase in immunosuppression to treat the rejection episode followed by a subsequent reduction in immunosuppression is recommended. No antiviral treatments for PVN have been approved by the Food and Drug Administration. Although the antiviral drug cidofovir has shown in vitro activity against murine polyomaviruses, and has been effective in some patients, it is associated with significant nephrotoxicity. Small series of patients treated with leflunomide and intravenous immune globulin therapy for PVN have also recently been reported. Retransplantation after graft loss due to PVN is feasible, but experience is limited. Current research is focusing on identifying PVN risk factors, refining screening, diagnostic and monitoring methods, and developing therapy for prophylaxis and treatment of PVN with the goals of decreasing the prevalence of PVN and improving allograft outcomes in renal transplant recipients diagnosed with PVN. This review will present recent advances in basic and clinical research related to PVN and renal transplantation.

Interactive effects of tunnel dilation on the mechanical properties of hamstring grafts fixed in the tibia with interference screws

The effect of dilation of the tibial tunnel on the strength of hamstring graft fixation using interference screws was evaluated. In all, 28 RCI screws were tested in male human tibia-hamstring constructs with tibial tunnels reamed or dilated to the respective size of the graft diameter. Dilation of the tibial tunnel failed to significantly enhance hamstring fixation. Grafts secured in dilated tunnels displayed an 11% greater resistance to the initiation of graft slippage (174+/-112 N) compared to their undilated controls (156+/-77 N, P=0.63). Dilation of the tibial tunnel increased the failure load by an average of 4%, independent of screw diameter (dilated specimens: 360+/-120 N, controls: 345+/-88 N, P=0.74). Biomechanical research on the effect of tibial tunnel dilation in hamstring fixation has not provided satisfactory evidence as to the benefits of this additional surgical step during anterior cruciate ligament (ACL) reconstruction.

Using a management perspective to define and measure changes in nursing technology

AIMS

The aims of this paper are to discuss the uses of the concept of technology from the medical science and the management perspectives; to propose a clear definition of nursing technology; and to present a study applying the use of the concept of nursing technology on nursing units.

BACKGROUND

Nurse managers must use management terms correctly and the term technology may be misleading for some. A review of the nursing literature shows varied uses of the concept of technology. Thus a discussion of the dimensions, attributes, consequences, and definitions of nursing technology from the management perspective are given.

DESIGN

A longitudinal study to measure the dimensions of nursing technology on nursing units 10 years apart.

RESULTS

The findings suggest that the dimensions of nursing technology change over time and support the need for nurse managers to periodically assess nursing technology before making management changes at the level of the nursing unit.

CONCLUSIONS

This study helps health care providers understand the unique role of nurses as healthcare professionals by identifying and measuring nursing technology on the nursing unit.

Comparison of translocation of different types of microorganisms from the intestinal tract of burned mice

The aim of this study was to compare the ability of various microorganisms to translocate from the intestine to the mesenteric lymph nodes (MLNs), liver, and spleen in a burned mouse model. Balb/c mice were gavaged with 1 x 10(9) or 1 x 10(10) of one of 11 different microorganisms. All animals were then given a 20% burn. Survival after 10 days showed no significant difference between any of the groups at the 10(10) dose. At the 10(9) dose, significantly higher survival rates were found in three of the 11 strains. Microbial translocation (gavage of 10(10) 111In-labeled organisms) and host's ability to kill translocated bacteria (viable bacteria in tissues) were measured followed by burn injury and sacrifice four hours later. Translocation and killing of Staphylococcus epidermidis and Escherichia coli was high in the MLNs compared with all other groups but translocation was lower to the liver. Klebsiella, Pseudomonas, and Serratia translocated more evenly to all the tissues. However, these groups showed very high clearance of bacteria in the liver and spleen except for Klebsiella and one strain of Pseudomonas in the spleen. Candida showed poor translocation to all of the tissues and high clearance. It is concluded that various strains of bacteria translocate from the intestine to a similar degree after injury, but the tissues to which they translocate and the rate at which they are killed are somewhat strain dependent.

Oral arginine improves blood pressure in renal transplant and hemodialysis patients

BACKGROUND

Hypertension in kidney transplant (KT) patients may result from attenuated whole-body nitric oxide (NO) content and abnormal NO-mediated vasodilation. Increasing NO bioavailability with L-arginine (ARG) could theoretically restore the NO-mediated vasodilatory response and lower blood pressure.

METHODS

In a prospective pilot study, 6 normotensive volunteers and 10 KT patients received oral supplements of ARG (9.0 g/d) for 9 days, then 18.0 g/d for 9 more days. Six hemodialysis (HD) and 4 peritoneal dialysis patients received the same dose for 14 days. Five KT patients received 30 mL/d of canola oil (CanO) in addition to ARG. Systolic (SBP) and diastolic (DBP) blood pressure, creatinine clearance (CCr), and serum creatinine (Cr) were measured at baseline, day 9, and day 18. In a subsequent study, 20 hypertensive KT patients with stable but abnormal renal function were randomized in a crossover study to start ARG-only or ARG+CanO supplements for two 2-month periods with an intervening month of no supplementation. SBP, DBP, CCr, and Cr were measured monthly for 7 months.

RESULTS

In the pilot study, ARG reduced the SBP in HD patients from 171.5 +/- 7.5 mmHg (baseline) to 142.8 +/- 8.3 mmHg (p = .028). In the crossover study, SBP was reduced from baseline (155.9 +/- 5.0 mmHg), after the first 2 months (143.2 +/- 3.2 mmHg; p = .03) and subsequent 2 months (143.3 +/- 2.5 mmHg; p = .014) of supplementation. DBP was also reduced after supplementation in both studies. CanO had no effect on blood pressure. Renal function did not change.

CONCLUSIONS

Oral preparations of ARG (+/-CanO) were well tolerated for up to 60 consecutive days and had favorable effects on SBP and DBP in hypertensive KT and HD patients.

Community Health Nursing Outcomes Inventory

The Community Health Nursing Outcomes Inventory (CHNOI) is a 48-item assessment instrument that measures client and nurse outcomes in community settings. The objective of this study was to test the psychometric properties and feasibility of the CHNOI. Results suggest that the CHNOI is an instrument that efficiently measures outcomes sensitive to nursing care in health services research. Managers and researchers may find this instrument useful to assess a community health program's effectiveness.

Immediate allograft dysfunction due to atheroembolic disease

Atheroembolic disease is a known cause of renal failure following invasive vascular procedures in patients with atherosclerosis. It is, however, not generally associated with renal transplant dysfunction. We report on a case of donor-transmitted atheroembolic renal disease, which led to an immediate loss of the transplant kidney in the operating room. Risk factors associated with this condition and methods to prevent this complication are discussed.

Sodium arsenite induces the stress response in the gut and decreases bacterial translocation in a burned mouse model with gut-derived sepsis

Bacteria translocation from the bowel to systemic organs after burn injury may contribute to or be a cause of sepsis and multiple organ failure. The stress response confers protection under stressful conditions that would otherwise lead to cell damage or death. We investigated whether prior induction of the stress response by sodium arsenite could affect bacterial translocation after thermal injury. HSP-70, a highly stress-inducible protein, was used as a marker for induction of the stress response. Balb/c mice were intravenously injected with 4 mg/kg of sodium arsenite and killed at selected times post-treatment. Other treated mice were then gavaged with 10(10) E. coil or 10(10) 111In-labeled E. coil followed by a 20% burn. Survival was observed for 10 days. Mice gavaged with radiolabeled E. coil were killed 4 h post-burn to determine the effect of HSP-70 induction on microbial translocation in mesenteric lymph nodes (MLN), liver, and spleen. Sodium arsenite-injected mice showed HSP-70 induction in the ileum that increased in a time-dependent manner with peak expression 12 h post-injection. Treated mice showed a significantly higher survival rate (93%) than controls (46%; P < 0.05), and detection of 111In-labeled E. coli was significantly less in the liver and spleen (P < 0.05). These data show that sodium arsenite induced HSP-70 expression in the small intestine. The stress response was associated with significantly increased survival and significant decrease in detection of 111In-labeled E. coil in the liver and spleen in a burned mouse model with gut-derived sepsis.

Nutritional immunomodulation leads to enhanced allograft survival in combination with cyclosporine A and rapamycin, but not FK506

BACKGROUND

Recently, specific immunonutrients were found to increase experimental allograft survival when combined with cyclosporine A (CsA). This study compared the effect on rat cardiac allograft survival when nutritional immunomodulation was used with CsA, rapamycin (Rapa), or tacrolimus (FK506).

METHODS

Intra-abdominal ACI to Lewis cardiac allografts were performed and assessed daily by palpation. Study groups included untreated controls and those receiving CsA, Rapa, or FK506. Rats were fed ad libitum with Impact diet (fortified with fish oil, arginine, and RNA) or standard rat food. Further study groups were transplanted that received a donor-specific transfusion in addition to immunosuppression and diet.

RESULTS

Allograft survival was extended by combining Impact with CsA (45.3+/-19 days) and Rapa (165.3+/-52 days), but not FK506 (12.4+/-3.2 days). Mean graft survival in the Rapa/Impact group met criteria for functional tolerance. The addition of a donor-specific transfusion did not lead to graft survival advantages over similar groups not receiving a donor-specific transfusion.

CONCLUSIONS

The use of immunonutrients improves transplant outcome in animals treated with short courses of CsA and Rapa, but not FK506. These findings highlight the potential differences in the effects of nutritional immunomodulation with different immunosuppressive drugs in the treatment of transplant patients.

Cost effectiveness of a high-risk pregnancy program

This article presents an evaluation of an innovative community-based, case-management program for high-risk pregnant women and their infants. A 7-year analysis of the Medicaid claims from 182,196 pregnant women and those for 140,088 infants was conducted. The findings showed improved birth outcomes and a steady decrease in the cost of care for both pregnant women and their infants. Recommendations are made concerning implementation of this program in other settings with other clients.

Evaluation of pre- and posttransplant donor-specific transfusion/cyclosporine A in non-HLA identical living donor kidney transplant recipients. Cooperative Clinical Trials in Transplantation Research Group

BACKGROUND

The beneficial effects of donor specific transfusion (DST) have become controversial in the cyclosporine era. This study was performed to evaluate the potential benefits of a new protocol for administering DSTs in the perioperative period.

METHODS

Non-HLA identical living donor kidney transplant recipients were randomized prospectively to control or to receive a DST 24 hr before transplant and 7-10 days posttransplant. All patients received similar immunosuppression according to protocol.

RESULTS

The protocol had 212 evaluable patients (115 transfused and 97 control). There were no differences in 1- and 2-year graft and patient survival, causes of graft failure, incidence and types of infection, repeat hospitalization, or the ability to withdraw steroids. Immunological hyporesponsiveness (by mixed lymphocyte culture) occurred more frequently in transfused patients (18%) than controls (3%) (P = 0.04). Blood stored for > or =3 days was associated with fewer early rejections than blood stored < or =2 days. Overall, class II antigen mismatches were associated with more rejection episodes than class I antigen mismatches. However, transfused patients, but not control patients, with more class I antigen mismatches were more likely to have rejections.

CONCLUSIONS

Administration of DSTs by the method described had no practical influence on patient or graft survival for up to 2 years. However, donor-specific hyporesponsiveness was more common in transfused patients (18 vs. 3%). Longer follow-up will be needed to determine whether DST will be associated with long-term benefit.

Use of percutaneous transpedicular external fixation pins to measure intervertebral motion

STUDY DESIGN

Direct measurement of intervertebral motion was compared to motion determined by measuring the position of the exposed ends of the external fixation pins.

OBJECTIVES

To verify the accuracy of this technique, so that this protocol can be used to study intervertebral motion in the clinical setting.

SUMMARY OF BACKGROUND DATA

The transpedicular external fixation test has been shown to be a test that can predict the outcome of spinal fusion. In patients who are candidates for this test, intervertebral motion can be calculated from motion at the external ends of these pins.

METHODS

Six fresh cadaveric spinal segments from L2 to L5 were instrumented with titanium Schanz screws. Reflective markers were placed on the tips of the pins, and intervertebral motion was measured using a noncontacting camera system. Computed tomography data were used to determine the position of the vertebra relative to the reflective markers. Intervertebral distances were calculated and compared with direct measurements obtained using a three-dimensional digitizing arm.

RESULTS

There was an excellent correlation (r2 = 0.931) between the directly measured intervertebral motions and those that were indirectly calculated from measurements of motion at the end of the Schanz screws.

CONCLUSIONS

Intervertebral motion can be measured by monitoring motion of the ends of transpedicular external fixation pins. Motion of anatomic landmarks on the vertebrae can be calculated from the pin end's motion if computed tomography data are used to determine the geometric relation between the vertebrae and the external fixation pins. This validation study supports the use of this method in clinical investigations of intervertebral motion in patients with low back pain and external fixation.

Quantitative assessment of the midcarpal shift test

The subjective, clinical midcarpal shift test was compared with a quantitative measurement of carpal volar/dorsal translation versus ulnar deviation using a mechanical testing system. Testing was performed on 19 healthy volunteers (mean age, 33 years) and 3 patients (four wrists; mean age, 23 years) who had been diagnosed with ulnar midcarpal instability, a nondissociative form of carpal instability. During physical examination, each subject's wrist was graded I to V using the previously described classification of the degree of laxity and clunk observed with the midcarpal shift test. Each subject was also evaluated using a quantitative mechanical testing system that simulates the subjective clinical test. The testing system measures displacement of the distal carpal row, more specifically, the capitate, as the wrist is moved from neutral to ulnar deviation under a constant axial load of 44 N directed volarly at the head of the capitate. Reflective markers were attached to the skin above the proximal and distal ends of the third metacarpal and at the point where the 44-N load was applied to the carpus. Motion of the markers was used to calculate ulnar deviation and dorsal/volar translation of the carpus. The maximum slope of the carpal translation versus ulnar deviation curve was measured for each subject and compared with the results of the clinical midcarpal shift test. Higher maximum slopes were seen in subjects with the higher grades of carpal laxity. There were also differences with regard to the point at which the clunk occurred; the higher the clinical grade of laxity, the greater the ulnar deviation of the wrist at the point at which the clunk was observed. These differences were not significant, however. These data confirm the validity of the clinical test and establish its usefulness as a diagnostic indicator of midcarpal nondissociative carpal instability. The mechanized test also may be useful as a biomechanical marker, enabling the results of ligament sectioning to be effectively compared with defined clinical laxity.

Nitric oxide promotes the internalization and passage of viable bacteria through cultured Caco-2 intestinal epithelial cells

Nitric oxide (NO) may play an important role in the pathophysiology of intestinal barrier disruption. Our purpose was to investigate the effects of NO donors on the internalization and passage of bacteria through cultured intestinal epithelial cells. Human intestinal epithelial cell line Caco-2 cells were grown on microtiter plastic plates. The cells were incubated with Escherichia coli and sodium nitroprusside (SNP) or S-nitroso-N-acetyl-penicillamine (SNAP), as NO donors, at several concentrations. The numbers of viable bacteria internalized into the epithelial cells were measured. Caco-2 cells were also grown to confluency on membranes of bicameral systems. The cells were incubated with E. coli and SNP. The numbers of viable bacteria passed through the epithelial layer were determined. Viability of the bacteria and the intestinal epithelial cells after culture with SNP or SNAP were also determined. Both SNP and SNAP at .1 or 1 mmol/L increased the number of viable bacteria internalized into the enterocytes. Both 1 or 10 mmol/L SNP promoted bacterial passage through the intestinal epithelial layer. However, 10 mmol/L SNP decreased the number of viable Caco-2 cells and failed to increase the bacterial internalization into Caco-2 cells. Incubation of E. coli with SNAP at 10 mmol/L slightly decreased the number of viable bacteria and failed to increase the bacterial internalization into Caco-2 cells. We conclude that NO donors promote both the viable bacterial uptake and passage through the intestinal epithelial layer.

The effect of nutritional immunomodulation on cardiac allograft survival in rats receiving mycophenolate mofetil, cyclosporine A, and donor-specific transfusion

BACKGROUND

Immunosuppressive drugs continue to pose significant risks such as infection, toxicity, or neoplasia when used in long-term therapy. The investigation of newer and safer combined treatment strategies that decrease the need for these drugs is becoming increasingly important. Immunonutrients are known to have significant modulating effects on the immune system. Feeding with Impact, a commercially available diet enriched with arginine, omega-3 fatty acids, and RNA, recently has been shown to extend rat cardiac allograft survival when combined with a donor-specific transfusion (DST) and cyclosporine A (CsA). Because mycophenolate mofetil (MMF) is now commonly used in the clinical setting, the current study was designed to examine the effect on rat cardiac allograft survival when MMF was added to this immunosuppressive regimen.

METHODS

Intra-abdominal ACI to Lewis heterotopic cardiac allografts were performed. Study groups included untreated controls and recipients receiving varying combinations of a DST (1 mL) on the day prior to engraftment, MMF 45 mg/kg/day from the day of transplant through postoperative day six, and CsA 10 mg/kg on the day prior to operation and 2.5 mg/kg from the day of transplant through postoperative day 6. Animals were fed ad libitum with Impact diet or standard lab chow. Graft survival was determined by cessation of a palpable heartbeat.

RESULTS

Treatment with MMF led to a prolonged allograft survival over historical untreated controls. The combination of MMF with a donor-specific transfusion, Impact, or CsA was associated with an increase in graft survival over MMF alone. The addition of Impact to the combination of MMF and CsA resulted in further improvement. The most pronounced graft survival advantage was seen when Impact was combined with a DST and both of the immunosuppressive agents. One quarter of the animals in this group had a palpable donor heart beat at greater than 150 days, indicating functional tolerance in those animals.

CONCLUSIONS

The administration of Impact diet to treatment groups in this study was associated with graft survival advantages when compared to most of the other study groups receiving a similar drug regimen and standard chow. These findings support the importance of nutritional influences on allograft survival, and highlight the potential of diet therapy when used with short courses of clinically relevant immunosuppressive drugs.

The cost-effectiveness of transplantation with expanded donor kidneys

Transplantation with EDKs is a cost-effective therapy for ESRD as compared to hemodialysis across a variety of clinical and financial scenarios. In many cases the costs of pursuing transplantation with these donors will exceed hospital reimbursement for the procedure, providing a financial disincentive to pursuing a clearly cost-effective therapy.

Dietary amino acids as new and novel agents to enhance allograft survival

Dietary supplementation with arginine was previously found to enhance cardiac allograft survival in rats when given with a donor-specific transfusion and a short low-dose course of cyclosporine. This study was performed to determine further the role of amino acid supplementation in prolonging allograft survival. Standard isocaloric, isonitrogenous diets were modified to contain 2 or 4% of energy from arginine, 2 or 4% from glutamine, 4% from glycine or the following combinations: 2% arginine with 2% glutamine, 2% arginine with 4% glutamine, or 1% arginine with 2% glutamine. These diets were started along with a donor-specific transfusion and a 7-d course of cyclosporine the day before cardiac transplantation from an ACI to Lewis strain rat. Median survival times in days for the groups were as follows: control without amino acids, 19.0; 2% arginine, 68.0; 4% arginine, 35.5; 2% glutamine, 28.5; 4% glutamine, 53.5; 4% glycine, 31.5; 2% arginine with 2% glutamine, 39.5; 2% arginine with 4% glutamine, 42.5 and 1% arginine with 2% glutamine, 35.5. Each experimental diet except 2% glutamine and 4% glycine significantly enhanced allograft survival (P < 0.05) with the 2% arginine diet being the best (91.6 +/- 32.3 d [mean +/- SEM] versus 20.1 +/- 3.2 d for control). It is concluded that both arginine and glutamine enhance the immunosuppressive effects of donor-specific transfusion and cyclosporine.

The effect of sennosides on bacterial translocation and survival in a model of acute hemorrhagic pancreatitis

Bacterial translocation leading to subsequent infectious complications is a significant determinant of outcome in acute hemorrhagic pancreatitis (AHP). The colonic ileus and impaired intestinal barrier function that often accompany AHP may predispose to translocation. Sennoside is a naturally occurring cathartic and choleretic agent that stimulates intestinal mucous secretion and has potent promotility effects. The impact of sennoside-induced intestinal motility and secretory function on bacterial translocation and survival was studied in a rat model of AHP. Severe acute pancreatitis was induced in rats by the intraductal infusion of 2% sodium deoxycholate (DCA, 0.4 ml/kg). A group of sham-operated rats (group A) received intraductal saline, whereas experimental animals were subsequently administered distilled water (group B) or sennoside solution (group C) by gavage every 8 h. After 48 h, intestinal transit of fluorescein isothiocyanate-labeled dextran, serum endotoxin, and amylase levels, and bacterial translocation to mesenteric lymph nodes (MLNs) and pancreatic tissue were determined. The pancreas and intestine were sampled for histologic study. All group A animals survived and did not develop pancreatitis or endotoxemia, whereas groups B and C all demonstrated severe hemorrhagic pancreatitis with evidence of necrosis. Mortality at 48 h was 55% in group B versus 12.5% in group C. Inhibition of intestinal motility was noted in 40% versus 20%, and endotoxin levels were 61.36+/-28.26 pg/L versus 5.41+/-3.58 pg/L in group B versus group C rats, respectively (p<0.001). Pancreatic tissue and MLN cultures were positive in 100% of group B survivors versus 14% of group C survivors (p<0.05). Histologic examination of the intestine in group C animals showed increased mucous secretion, proliferation of goblet cells, and evidence of rapid turnover/renewal of enterocytes. Treatment with the cathartic agent, sennoside, reduced translocation of endotoxin and bacteria, restored intestinal motility, increased mucous secretion, and reduced mortality in a model of acute hemorrhagic pancreatitis in the rat. Other cathartics may have similar properties and may be useful in preventing infectious complications in acute pancreatitis.

Effect of pentoxifylline on survival and intestinal cytokine messenger RNA transcription in a rat model of ongoing peritoneal sepsis

OBJECTIVE

Septic animals receiving high-protein liquid diets have increased mortality and increased production of cytokines by the gut compared with animals receiving low-protein diets. The purpose of this study was to evaluate the ability of pentoxifylline to alter gut cytokine production in a rat model of prolonged acute peritonitis, to determine its effect on survival in such animals, and to determine whether alteration of gut cytokine production was associated with survival.

DESIGN

Prospective, randomized animal study.

SETTING

Research laboratory.

SUBJECTS

Male Lewis rats weighing between 250 and 300 g.

INTERVENTIONS

Anesthetized rats had placement of a gastrostomy, followed 1 wk later by implantation of a bacteria-filled osmotic minipump into the peritoneal cavity. Rats were fed a high-protein (20% total energy) enteral diet. Saline or pentoxifylline (5 or 20 mg/kg im) was administered daily beginning at the time of pump implantation.

MEASUREMENTS AND MAIN RESULTS

Septic rats fed the high-protein liquid diet and given pentoxifylline in a dose of 5 mg/kg/day demonstrated improved survival compared with saline-treated animals or animals given the high dose (20 mg/kg/day) of pentoxifylline (p< .05). Administration of pentoxifylline at 5 mg/kg/day also down regulated the production of IL-6 messenger RNA (mRNA) in liver and lipopolysaccharide binding protein mRNA in the liver and intestine of septic animals given the high-protein liquid diet.

CONCLUSION

Low-dose (but not high-dose) pentoxifylline administration reduced production of some, but not all, cytokines studied in the gut and liver in a rat model of acute peritonitis and this reduced production was associated with an improved survival in such animals.

Use of tacrolimus eliminates acute rejection as a major complication following simultaneous kidney and pancreas transplantation

This retrospective study illustrates the efficacy of tracrolimus-based immunosuppression following simultaneous kidney and pancreas transplantation. Between March 1995 and December 1996, 24 simultaneous kidney and pancreas transplant recipients received tacrolimus-based maintenance immunosuppression. All patients received sequential therapy with an antilymphocyte agent, azathioprine, prednisone and tacrolimus. The dose of tacrolimus was adjusted to achieve a whole blood trough level of 8-15 ng/mL (IMx). The mean follow-up was 25 months with a median of 26 months (range 12-33 months). A rise in serum creatinine of > 20% over baseline was investigated with a renal biopsy, after mechanical causes for renal dysfunction had been excluded. Mean serum creatinine concentrations at 3, 6, 12, 18 and 24 months post-transplantation were 1.1, 1.2, 1.3, 1.3 and 1.3 mg/dL respectively. The blood glucose concentrations at the corresponding time period were 115, 94, 95, 93 and 95 mg/dL. Four pancreas allografts were lost (three in the immediate post-transplant period due to thrombosis, and one following iliac artery repair for aneurysm). Transient hyperglycemia requiring treatment was seen in 3 patients. There were four (17%) acute rejection episodes--one of the pancreas allograft alone and three involving the kidney. At a mean follow-up of 25 months, the patient survival and renal allograft survival were 100%, with pancreas allograft survival rate of 78.4% (Kaplan-Meier analysis). Nine (37.5%) patients had evidence of tacrolimus toxicity on renal histology. In conclusion, tacrolimus-based maintenance immunosuppression is associated with stable renal and pancreas allograft function, with freedom from acute rejection in 83% of patients.

Immunonutrition: the role of omega-3 fatty acids

The dietary fatty acids of the omega-3 series are rapidly incorporated into cell membranes and profoundly influence biological responses. These lipids influence membrane stability, membrane fluidity, cell mobility, the formation of receptors, binding of ligands to their receptors, activation of intracellular signaling pathways either directly or through the formation of eicosanoids, gene expression, and cell differentiation. In general, eicosanoids formed from the omega-3 fatty acids are much less potent in causing biological responses than those formed from the omega-6 fatty acids, including stimulation of cytokine production and inflammatory responses. In well-controlled clinical studies, consumption of omega-3 fatty acids has resulted in reduction of cardiovascular diseases including arrhythmias and hypertension, protection from renal disease, improvement in rheumatoid arthritis, improvement in inflammatory bowel diseases, reduced episodes of rejection, and protection from infection. The interactions between the omega-3 fatty acids and pharmacologic drugs that alter intracellular signaling pathways are only now being studied.

Characteristics of long-term renal transplant survivors

Despite the high rates of rejection, allograft failure, and patient death in the early years of renal transplantation, some patients have done remarkably well. Forty-three (17 living related donor and 26 cadaver donor recipients) such patients with an allograft that functioned for 19 years or more (range, 19 to 29 years) were followed up at this center. The patients included 24 men and 19 women, with a mean age at transplantation of 29 years, of whom 39 were white and four were black. At most recent follow-up, the mean daily dose of azathioprine was 104 mg (range, 50 to 175 mg) and that of prednisone was 10 mg (range, 5 to 20 mg). Mean serum creatinine level was 1.6 mg/dL (range, 0.7 to 5.4 mg/dL). Acute rejection occurred in 14 (33%) patients. Nine patients had one episode and five patients had two episodes of acute rejection. Long-term risks to the recipients appeared in the form of coronary artery disease in 10 (23%) patients; malignancy in 13 (30%) patients, which included nine patients with skin malignancy; and chronic hepatitis C virus (HCV) infection in four patients, two of whom died of complications of liver failure. Other complications included avascular bone necrosis in five patients, which required total hip replacement in two patients; hyperlipidemia requiring treatment in 16 (37%) patients; posttransplantation diabetes mellitus in 10 (23%) patients after a median of 17.5 years (range, 1 to 23 years); and hypertension in 23 (53%) patients. There were seven deaths (three of coronary artery disease, two of liver failure, one each of sepsis and malignancy) and eight graft losses (five to death with function, two to chronic rejection, and one to focal and segmental glomerulosclerosis). Although long-term allograft success results in patients receiving minimal amounts of immunosuppression and having good renal function, long-term renal transplant survivors are at risk for significant morbidity even in the third decade posttransplantation.

Dietary omega-3 and omega-9 fatty acids uniquely enhance allograft survival in cyclosporine-treated and donor-specific transfusion-treated rats

BACKGROUND

Both laboratory and clinical studies have shown that dietary lipids may affect immunologic responses. This study was conducted to compare different classes of long-chain unsaturated fatty acids for their effect on allograft survival in animals receiving a donor-specific transfusion and a short course of low-dose cyclosporine (CsA).

METHODS

Heterotopic ACI strain cardiac allografts were transplanted to Lewis strain rat recipients given diets with different lipid composition. In experiment 1, animals received CsA for 14 days and different diets were enriched with lipids with high concentrations of omega-3, omega-6, or omega-9 fatty acids. In experiment 2, animals received CsA for only 8 days and different diets were enriched with corn oil (omega-6), canola oil (omega-3 and omega-9), fish oil (omega-3) or a mixture of sunflower oil and fish oil (omega-3 and omega-9).

RESULTS

In experiment 1, animals receiving the diet with 30% sunflower oil had the best allograft survival (200+/-42 days vs. 53+/-8 days for regular chow plus donor-specific transfusion and CsA, P<0.05). In experiment 2, diets containing canola oil (a mixture of omega-3 and omega-9 fatty acids) were associated with the best survival (P=0.0011 vs. regular chow).

CONCLUSION

Dietary omega-3 and omega-9 fatty acids both enhanced cardiac allograft survival in a stringent rat strain combination. Canola oil is a convenient oil for administering both alpha-linoleic acid (omega-3) and oleic acid (omega-9) in a palatable form for human consumption. Further investigation of the potential usefulness of lipids in transplant therapy is warranted.

The relationship of job satisfaction with organizational variables in public health nursing

OBJECTIVE

This study examined the relationship of the organizational variables of structure, technology, and environment with job satisfaction among public health nurses in a southeastern state.

BACKGROUND

There is little research on the characteristics of the work environment that influence nurses to remain in the public health work setting. Prior research in this setting has focused on the negative aspects of the nursing positions. These aspects of least desirability for the public health nurse provide only a partial view of job satisfaction. To decide and plan specific strategies, the nurse administrator must have valid and useful information about the positive aspects of job satisfaction of public health nurses.

METHODS

The researchers distributed a questionnaire to all licensed nursing personnel employed by a state public health department. Data collection consisted of four tools: 1) structure instrument; 2) technology instrument; 3) environmental uncertainty instrument; and 4) McCloskey-Mueller Job Satisfaction Scale (MMSS). The sample of 838 public health nurses (response rate of 50.6%) included representation from all 13 districts and the central office of the public health department.

RESULTS

Significant relationships were found between job satisfaction and the demographic variables of nurse category (registered nurse and licensed practical nurse) and years of experience with the public health department. The critical variable for predicting job satisfaction in this group of public health nurses was organizational structure (vertical participation, horizontal participation, and formalization). Dimensions of structure accounted for 41% of the variance in job satisfaction. Structure remained the critical predictor of job satisfaction, although the findings do not suggest a conclusive model. The three dimensions of technology (instability, variability, and uncertainty) and environmental uncertainty assumed significance only in concert with each other or with the dimensions of structure.

CONCLUSIONS

This study contributes to nursing management theory by examining the relationship of organizational structure, technology, and environmental uncertainty with job satisfaction in public health nurses. This research also has implications for nurse administrators in public health for creating more flexible work environments and facilitating staff involvement in decision making.

Optimal location of a single distal interlocking screw in intramedullary nailing of distal third femoral shaft fractures

OBJECTIVE

This biomechanical study was done to determine the effect of the level of a single distal screw in a static intramedullary (IM) femoral nail on the stability of fixation of a fracture in the distal third of the femur.

DESIGN

Fifteen composite fiberglass femora were osteotomized transversely in the distal third of the femur. A Grosse-Kempf nail was implanted into the femurs, which were divided into three groups of five specimens. Single screw distal nail locking was varied distal to the osteotomy site for each group at 2.5, 5.0, and 7.5 centimeters, respectively.

INTERVENTION

All instrumented femurs were mounted on a servohydraulic testing machine and fitted with transducers to measure axial, rotational, and bending displacements. Specimens were cyclically loaded (one hertz) in simultaneous torsion (moment: +/- 10 newton-meters) and axial compression (amplitude: 2,000 newtons) for 500 cycles with a 250-pound abductor force.

MAIN OUTCOME MEASUREMENT

Data from linear and rotational transducers were sampled at 100 hertz for five cycles before cycling, every 100 cycles of loading, and immediately after cycling. Custom computer software was developed to convert transducer signals into static and dynamic measurements of axial motion (in millimeters), rotation (in degrees), and angulation (in degrees).

RESULTS

Osteotomy site dynamic rotation increased significantly in specimens locked at 7.5 centimeters when compared with the 2.5-centimeter group. There was minimal difference between the stability of the 5.0-centimeter and 7.5-centimeter groups. There was no significant change in position at the fracture site before or after cyclic loading with respect to axial shortening, rotation, or bending. Both dynamic axial and angular displacements were also unaffected by screw position.

CONCLUSION

The location of a single distal interlocking screw in static IM nail fixation of distal third femur fractures can significantly affect rotational stability but not axial or angular fixation.

Arginine, fish oil, and donor-specific transfusions independently improve cardiac allograft survival in rats given subtherapeutic doses of cyclosporin

BACKGROUND

Dietary supplementation with a fish oil and arginine-enriched immunoenhancing diet (Impact; Sandoz Nutrition, Minneapolis, MN) in a rat cardiac allograft model using donor-specific transfusion (DST) and cyclosporin (CsA) resulted in significant prolongation of cardiac allograft survival with many animals developing long-term tolerance. This study was done to determine whether arginine or fish oil was the active ingredient.

METHODS

A standard AIN-76A diet was modified to include either 10% fish oil, 2% arginine, or 5% arginine with or without fish oil. Diets were fed to Lewis strain rats that received Ax C9935 Irish (ACI) heterotopic cardiac allografts beginning on day 1 and continuing indefinitely. A DST (1.0 mL ACI whole blood) was given with 10 mg/kg CsA on day 1 relative to transplant and 2.5 mg/kg/d on days 0 to 6. Groups of animals receiving AIN-76A diet fortified with 2% glycine and animals receiving a DST or DST/CsA and regular laboratory chow served as controls.

RESULTS

Mean survival times +/- SEM in days were as follows: untreated, 7.1 +/- 0.4; CsA/2% glycine, 8.5 +/- 0.6; DST only, 9.6 +/- 1.1; DST/CsA, 26.6 +/- 6.4; CsA/2% arginine, 25.5 +/- 3.9; DST/CsA/2% arginine, 68.7 +/- 8.9; DST/CsA/5% arginine, 90.1 +/- 31.1; CsA/fish oil, 73.6 +/- 26.1; and DST/CsA/fish oil/5% arginine, 90.1 +/- 31.1. The effect of arginine was slightly dose dependent and was seen best in combination with DST, but the effect of fish oil was not enhanced by DST.

CONCLUSIONS

Both fish oil and arginine dietary supplementation significantly improved allograft survival but through different mechanisms (DST vs non-DST dependent).